Background: The COVID-19 pandemic, caused by SARS-CoV-2, is of a scale not seen since the 1918 influenza pandemic. Although the predominant clinical presentation is with respiratory disease, neurological manifestations are being recognised increasingly. Based on knowledge of other coronaviruses, especially those that caused the SARS and MERS epidemics, we might expect to see rare cases of central nervous system (CNS) and peripheral nervous system (PNS) disease caused by SARS-CoV-2.

Recent developments: A growing number of case reports and series describe a wide array of neurological manifestations, but many lack detail, reflecting the challenge of studying such patients. Encephalopathy is relatively common, being reported for 93 patients in total, including 16 (7.5%) of 214 hospitalised COVID-19 patients in Wuhan, China, and 40 (69%) of 58 in intensive care with COVID-19 in France. Encephalitis has been described in 8 patients to date, and Guillain-Barre syndrome in 19 patients. SARS-CoV-2 is detected in the cerebrospinal fluid of some patients. Anosmia and ageusia are common and may occur in the absence of other clinical features. Unexpectedly, acute cerebrovascular disease is also emerging as an important complication, with cohort studies reporting stroke in 1.6-6% of hospitalised COVID-19 cases. So far, 88 patients have been described, mostly with ischaemic stroke, who frequently have vascular events in the context of a pro-inflammatory hypercoagulable state with elevated CRP, D-dimer, and ferritin.

Where next?: Careful clinical, diagnostic and epidemiological studies are needed to help define the manifestations and burden of neurological disease caused by SARS-CoV-2. Precise case definitions must be used to distinguish non-specific complications of severe disease, such as hypoxic encephalopathy and critical care neuropathy, from those caused directly or indirectly by the virus; these include infectious, para- and post-infectious encephalitis, hypercoagulable states leading to stroke, and acute neuropathies such as Guillain-Barre syndrome. Recognising SARS-CoV-2 neurological disease in patients whose respiratory infection is mild or asymptomatic may prove challenging, especially if the primary COVID-19 illness occurred weeks earlier. The proportion of infections leading to neurological disease will remain small. However, these patients may be left with severe neurological sequelae. With so much of the population infected, the overall number of neurological patients, and their associated health, social and economic costs, may be large. Healthcare planners and policymakers must prepare for this eventuality. The many ongoing studies investigating the neurological association will increase our knowledge base.

/pdf/neurological-associations-of-covid-19-o39p8yig6g.pdf

Neurological Associations of COVID-19

Coronaviruses mainly affect the respiratory system; however, there are reports of SARS-CoV and MERS-CoV causing neurological manifestations. We aimed at discussing the various neurological manifestations of SARS-CoV-2 infection and to estimate the prevalence of each of them. We searched the following electronic databases; PubMed, MEDLINE, Scopus, EMBASE, Google Scholar, EBSCO, Web of Science, Cochrane Library, WHO database, and 
ClinicalTrials.gov

. Relevant MeSH terms for COVID-19 and neurological manifestations were used. Randomized controlled trials, non-randomized controlled trials, case-control studies, cohort studies, cross-sectional studies, case series, and case reports were included in the study. To estimate the overall proportion of each neurological manifestations, the study employed meta-analysis of proportions using a random-effects model. Pooled prevalence of each neurological manifestations are, smell disturbances (35.8%; 95% CI 21.4–50.2), taste disturbances (38.5%; 95%CI 24.0–53.0), myalgia (19.3%; 95% CI 15.1–23.6), headache (14.7%; 95% CI 10.4–18.9), dizziness (6.1%; 95% CI 3.1–9.2), and syncope (1.8%; 95% CI 0.9–4.6). Pooled prevalence of acute cerebrovascular disease was (2.3%; 95%CI 1.0–3.6), of which majority were ischaemic stroke (2.1%; 95% CI 0.9–3.3), followed by haemorrhagic stroke (0.4%; 95% CI 0.2–0.6), and cerebral venous thrombosis (0.3%; 95% CI 0.1–0.6). Neurological symptoms are common in SARS-CoV-2 infection, and from the large number of cases reported from all over the world daily, the prevalence of neurological features might increase again. Identifying some neurological manifestations like smell and taste disturbances can be used to screen patients with COVID-19 so that early identification and isolation is possible.

/pdf/neurological-manifestations-of-covid-19-a-systematic-review-3zp764bbbn.pdf

Neurological manifestations of COVID-19: a systematic review and meta-analysis of proportions.

Introduction:Studies revealed COVID-19 atypical symptoms such as falls, delirium, confusion, dizziness, unusual fatigue in older patients. Falls in the older population and their consequences are o...

https://journals.sagepub.com/doi/pdf/10.1177/2151459321996619

Falls as One of the Atypical Presentations of COVID-19 in Older Population

Background Nursing home residents are generally old and frail, and at high risk that COVID-19 will take a serious course. Outbreaks of COVID-19 have not previously been described in Norway, and it is important to identify mechanisms for spread of the infection and course of disease for nursing home residents with this pandemic disease. Material and method We included residents from three nursing homes with outbreaks of COVID-19 in a retrospective observational study, and we retrieved information on the number of staff for whom SARS-CoV-2 was confirmed or who were placed in quarantine. We present resident characteristics, course of disease and mortality associated with COVID-19 in the nursing homes, as well as providing a brief description of the outbreaks. Results Forty residents were included, 26 of whom were women. The average age was 86.2 years. Thirty-seven of the residents had atypical symptoms, nine of them were asymptomatic at the time of diagnosis, and 21 died during the coronavirus infection. Contact tracing indicated that the outbreaks may have originated from staff in the pre-symptomatic or early and mild phase of the disease. SARS-CoV-2 was detected in forty-two staff members, and a further 115 were placed in quarantine. Interpretation Many residents had atypical disease presentation, and the mortality from COVID-19 was high. Spread of infection may have originated from staff, also before they displayed obvious symptoms, and contributed to extensive spread of SARS-CoV-2 in the three nursing homes.

/pdf/outbreak-of-covid-19-at-three-nursing-homes-in-bergen-3giq73cwwx.pdf

Outbreak of COVID-19 at three nursing homes in Bergen

The frailty index (FI) quantifies frailty as deficit accumulation. It has been adapted to employ laboratory test data (FI-Lab). Our objective was to systematically review and meta-analyse the FI-Lab's ability to predict mortality. Secondary objectives were to review the FI-Lab's association with adverse health outcomes and whether FI-Lab scores differed between the sexes. A systematic literature search was carried out using six online databases to identify studies that measured the FI-Lab in humans. Hazard ratios (HRs) were combined in a meta-analysis to create a pooled risk estimate for mortality. Of the 1,201 papers identified, spanning January 2010 until 11 July 2022, 38 were included. FI-Lab scores per 0.01 unit increase predicted mortality overall (HR = 1.04; 95% confidence interval (CI) = 1.03-1.05) and for studies with a mean age of 81+ years (HR = 1.04; 95% CI = 1.03-1.05). The quality of evidence for these meta-analyses are moderate and high, respectively. Further, higher FI-Lab scores were associated with more frequent adverse health outcomes. Sex differences in FI-Lab scores varied, with no consistent indication of a sex effect. The FI-Lab is associated with mortality and with a variety of adverse health outcomes. No consistent sex differences in FI-Lab scores were observed, with several studies in disagreement. Notably, these conclusions were most relevant to older (65+ years old) individuals; further evidence in younger people is needed in both clinical and population representative studies.

The frailty index based on laboratory test data as a tool to investigate the impact of frailty on health outcomes: a systematic review and meta-analysis.

https://link.springer.com/content/pdf/10.1007/s41999-021-00555-8.pdf

Association between clinical frailty, illness severity and post-discharge survival: a prospective cohort study of older medical inpatients in Norway.

COVID-19 in an elderly woman with acute functional decline.

/pdf/new-consciousness-scale-for-delirium-ibuumh2hfj.pdf

New consciousness scale for delirium.

\n A woman in her late eighties was referred to Accident and Emergency because of acute functional decline with falls and increasing confusion. SARS-CoV-2 infection was confirmed 48 hours later. Many older people and residents of care homes are vulnerable to functional decline with acute illness. Healthcare professionals should be aware that such symptoms may be due to COVID-19.\n

Covid-19 påvist hos eldre kvinne med akutt funksjonssvikt./ Covid-19 påvist hos eldre kvinne med akutt funksjonssvikt./ COVID-19 in an elderly woman with acute functional decline.

/pdf/scope-of-treatment-and-clinical-decision-making-in-the-older-3sy44h0q.pdf

Scope of treatment and clinical-decision making in the older patient with COVID-19 infection, a European perspective

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